New Client Skin Care Questionnaire

Personal and Confidential

If you are a new client, please fill out the form below so we can create a personalized skin care plan customized for you. Once you submit the form, it usually takes less than 1 business day to get a response.

1. Please provide the following information for the person this Skin Care Plan is for:

First Name :*

Last Name :*

Please Enter your email address :*

Address :*

Phone number :*

How old are you? :*

Are you male or female? :*

malefamale

2. Concerns & Interests

1. What skin problems or concerns would you like to address?

2. What would you like to change about your skin?

3. What would you like to change about your skin?

4. What skin care products do you currently use?

3. Current Health & Lifestyle

1. What skin problems or concerns would you like to address?Dry (facial skin is very dry)Oily (entire face is very oily)Combination (t-zone tends to be oily)Normal

2. Do you have acne?yesno

3. If you have acne how would you characterize the severity?Mild (red bumps and pustules that come & go)Moderate (red bumps and pustules that come & go)Severe (presistent nodules & cysts that are resistant to treatment)N/A

4. Are you currently taking accutane, Antibiotics and Brith Control pills?yesno

5. Have you been diagnosed with rosacea or psoriasis?RosaceaPsoriasisNo

6. Have you ever had a chemical peel?yesno

If yes, which type:

approximate date: (mo./year)

7. Have you had an allergic or irritant reaction to a skin care product(s)?yesno

8. Do you use sunscreen regularly?yesno

SPF:

9. Do you use a tanning booth?yesno

How often:

10. Do you sunbathe?yesno

How often:

11. When did you last see a dermatologist?Never6 Months1 Year2 Year

12. Have you had any cosmetic procedure or laser surgery in the past six months?yesno

13. Please check if you have a history of the following health conditions:Bleeding ProblemsSkin CancerStomach UlcersHigh Blood PressureHivesTuberculosisX-Ray TherapyHeart MurmurCardiac PacemakerEczemaFainting SpellsOther

14. Are you pregnant?yesno

15. Do you have any medical conditions or experience any allergic reactions to skin care products?yesno

16. Do you have any of the following skin conditions?Enlarged poresBlotchy or uneven pigmentSaggy facial skinFine lines around eyes and mouth

17. Is there any other information that might be helpful to know about you?